MEDICARE: STEPHEN LEE WILTZEN PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	94 PT	MT

General Provider Information

NPI Number	:	1821165127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN LEE WILTZEN PT

Provider Business Mailing Address
First Line	:	851 BRIDGER DRIVE
Second Line	:	SUITE 5
City	:	BOZEMAN
State	:	MT
Zip	:	59715-1803
Country	:	US
Telephone Number	:	406-586-7288
Fax Number	:	406-586-0219

Provider Business Practice Location Address
First Line	:	851 BRIDGER DRIVE
Second Line	:	SUITE 5
City	:	BOZEMAN
State	:	MT
Zip	:	59715-1803
Country	:	US
Telephone Number	:	406-586-7288
Fax Number	:	406-586-0219

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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